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Tamil Nadu Hostels and Homes for Women and Children (Regulation) Rules, 2015

Appendix

Form I

[See Rules 3 (1), 3(6) ]

Application form for Licence and Renewal of Licence

1. Name of the institution and address ..
Phone number ..
Fax ..
E-mail ..
2. Place of the institution ..
(i) Registered place ..
(ii) Current place ..
3. Nature of the home ..
[hostel or lodging house or home for women and children] ..
4. Name and address of the contact person ..
5. Details of the governing body (managing committee/ executive committee) ..
6. Under which Act the registration is made ..
(i) number, date and place of registration ..
(ii) If renewed, the renewal details ..
7. Number of inmates admitted / to be admitted in the institution. ..
8. Total number of girls or boys or women ..
(i) Girls ..
(ii) Boys ..
(iii) Women ..
9. Infrastructure available in the hostel or lodging house or home for women and children.- ..
(i) Total area of the campus. ..
(ii) Total living area of the building including the living area provided to each inmate, kitchen, dining hall, store room, sick room, first aid room, library, separate bathrooms and toilets for girls and boys, officer room, manager or resident manager or warden or care taker's / care giver's room. ..
(iii) Plinth area of each floor of the building. ..
(iv) Number of floors. ..
(v) Play ground. ..
(vi) Details of building available for academic programme with specifications. ..
(vii) Details of facilities available for (i) vocational * (ii) Socio-cultural recreational # (iii) Eco friendly ** programmes with specifications. ..
* Tailoring, embroidery, printing, maintenance of electrical and electronic appliances, motor mechanism, carpentry, plumbing and any other non hazardous items with the permission of concerned District Collector.
# Teaching musical instruments, yoga, dance, gymnastics, arts and painting, cookery, games like cricket, tennis, football, basketball, badminton, chess, carom and other indoor and outdoor games except swimming.
** Gardening, tree planting, waste management, landscaping, bio-composting and any other non hazardous items with the permission of concerned District Collector.
(viii) Building stability certificate and sanitation certificate obtained either from Public Works Department / Registered Chartered Engineer+/ Registered Chartered Architect+ (mention the year specifically). ..
(ix) Certificate from Fire Service and Rescue Department. ..
10. (i) Number of rooms allotted for girls in the age group of 5 to 10 ..
(ii) Number of rooms allotted for girls in the age group of 11 to 18 ..
11. (i) Number of rooms allotted for boys in the age group of 5 to 10 ..
(ii) Number of rooms allotted for boys in the age group of 11 to 18 ..
12. Number of rooms allotted for women ..
13. Details of the manager / resident manager/ care taker's or care giver's / warden (men or women) appointed in the institution. ..
(i) Name ..
(ii) Age ..
(iii) Educational qualification ..
(iv) Date of joining ..
(v) Appointed by whom ..
(vi) Salary ..
(vii) Medical certificate ..
(viii) Conduct certificate ..
14. Details of entry and exit points in the institution ..
15. Details of security person appointed in the institution ..
(i) Name ..
(ii) Age ..
(iii) Educational qualification ..
(iv) Date of joining ..
(v) Salary ..
(vi) Medical certificate ..
(vii) Conduct certificate ..
16. (i) Specify locations where the CCTV cameras have been installed. ..
(ii) If not installed, action taken to install the same. ..
17. Details of menu provided ..
18. Details of rooms allocated for manager or resident manager or warden or caretaker / care giver or security persons. ..
19. Details of the compound wall built around the institution. + as prescribed in Form VIII. ..
20. Bathroom / toilet facilities provided. ..
21. Details of the children going to schools. ..
22. The amount collected from parents. ..
23. Details of registers maintained in the institution ..
24. Details of the visitors room and visiting hours. ..
25. Details of the supervision of the visitors during the visiting hours. ..
26. Details of the supervision when the inmates are going on holidays or leaving the hostel or lodging house or home for women and children. ..
27. Details of the identity cards issued to the warden or caretaker / care giver or security persons by the institution. ..
28. Details of the photo identity cards issued to the parents or guardians by the institution. ..
29. Details of the mobile number of warden or care taker / care giver or security persons displayed on the entrance. ..
30. Details of the child help line number 1098 displayed in the institution. ..
31. The details and phone number of the institution registered in district website. ..
32. The details of the inmates registered in track child website. ..
33. The details of review meeting and resolution taken by the Non-Governmental Organization for past two months. ..
34. Audit statement details for the past three years done by the chartered accountant. ..
35. Annual turnover ..
36. Foreign Contribution Regulation Act details ..
37. Bank account number ..
Bank name and branch ..
38. Other facilities ..
(i) Medical facilities. ..
(ii) Other social activities run by the institution. ..
39. Linkage with other institution detail ..
Name of the institution and help received from them ..
(i) Food ..
(ii) Recreation facilities ..
(iii) Medical facilities ..
(iv) Technical education ..
(v) Yoga and meditation ..
(vi) Others ..
I declare that the facts mentioned above is absolutely true to the best of my knowledge.
Place:
Date & Seal:

Signature of the Applicant





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